Dr. BORHANI. Well, you might know, Senator, that in California we went into program budgeting for the next fiscal year. In our program budget, we have two objectives in this particular area.

One is to make available in the next fiscal year, over and above our present activities, five comprehensive centers for early detection of chronic diseases in five geographic areas of the State.

The second objective we have is the two points mentioned in the Governor's message to you.

Under title XIX of Public Law 89-97, we have what is called the Medi-Cal program. With the assistance of local health departments, local medical societies, and local societies and clinics, we are developing comprehensive multiphasic examinations in local communities for recipients of this program.

And I might add that we also are developing a very comprehensive program in the Watts area in cooperation with the University of Southern California. In the Fresno area, there is a program directed toward a special segment of our population.

Senator NEUEERGER. A very wonderful report. Thank you very much.

We will now hear from Dr. Lester Petrie, who is director of the Branch of Preventable Diseases of the State of Georgia.

STATEMENT OF DR. LESTER M. PETRIE, DIRECTOR, BRANCH OF PREVENTABLE DISEASES, DEPARTMENT OF PUBLIC HEALTH, STATE OF GEORGIA, ATLANTA, GA.

Dr. PETRIE. Senator Neuberger, I, too, want to congratulate you and your subcommittee, and thank you for the privilege of presenting my particular thoughts to you.

Before I summarize my paper, there is one observation on one comment that was made by Dr. Swartz, a short time ago, that recalls something to my mind that I would like to put in the record.

That was his comment that the findings, the screen test findings, should be reported only through the physician to the patient.

There is no disagreement between me and Dr. Swartz, I think, on the fact that tests are meaningless unless interpreted by a physician. That is certainly a fact.

But there is a difficulty here introduced by the fact that in our screening of a million and a half persons, and in the samples that we have collected since then, we have quite consistently observed that approximately 75 percent of the people who consult a physician after going through this screening line do not go to the physician whose name they gave us as they went down the line, but do go to someone else. I mean the ones that go to a physician go to a different physician from the one whose name they gave us.

Now, I think it is entirely in order that a patient should have the privilege of changing his choice of physician, and I think that it is irritating to a physician to get a report of a battery of screening tests for a patient that never comes to him.

And it is also rather valueless for the battery of screening tests not to go to the physician to whom it should go.

In summarizing my paper, I have called attention to the fact that 21 years ago the Georgia Department of Public Health pioneered in

multiple-test health screening, and for nearly 7 consecutive years, beginning in October 1945, an average of 17,500 persons per month went through our screening tests for 80 consecutive months, a total of 1.4 million people.

And this was at an average cost of $1.03 per person tested.

On the other side of the coin, it was a million and a half dollars. This measure of success was possible only because of the close harmony existing between the Public Health Department and the medical profession, and mutual support by both the State and local medical profession and health departments.

In my paper, of course, I have summarized some of our findings, and also some of the conclusions we drew from those findings, and in addition, some of the consequences of certain chronic illnesses, and some of the costs.

These matters have all been quite thoroughly covered by other people, and I am going to skip over, even in my summary of the paper, here, to the thing that I really came up here to say to you folks.

We discontinued large-scale, community wide, multiphasic health service in Georgia in 1953.

The major reason that we discontinued at that time was the very sharp reduction in appropriations.

But we have not yet reinstituted large-scale multiphasic screening on a community wide basis for another equally, or even more basic, reason. And that reason is that our communities have not yet developed the resources to assure the availability of adequate medical diagnosis and care to all of the suspects that we find by the surveys, nor to identify and control all of the other key factors which interrelate to affect the course and progress of disease in the community.

Senator Neuberger, I learned something this morning which has caused me to make a small but significant change in the wording of my written report, on page 205, and I call your attention to this:

"I can now see little reason for the Government to underwrite all the expense of health screening for industries and businesses and the professions and the labor force, and the members of their households whom they support with their dividends and their salaries and wages."

All of us who work for a living are members of the labor force. Industrial and medical leaders, as with the Kaiser industries and the Permanente group, have demonstrated that with a little help they can organize themselves and do the job, and pay for most of it out of earned income.

This is as it should be in the free American tradition.

We cannot afford to ignore this occupational health approach.

That is what I really came to tell you folks. For the occupational health approach deals with those who produce the wealth which we need, and who represent the population and support the population which we serve.

You know, we are all the same people. I am a member of the labor force, and I am a professional person, and I am the same guy.

And I would like to call your attention, on page 205, to the box which shows the general population and the labor force and the households in the United States and in Georgia, in the 1960 census.

Now, what that teaches us is that in Georgia, our one and a half million labor force, which includes all of us who work for a living, sup

port the one and a tenth million households in which our 4 million citizens live.

"Take Home Health" learned on the job could be of universal value; if the entire population at risk is our ultimate target, the labor force is the bull's-eye.

If big business or big industry or big government perfects a health center for its own employees, why cannot it contract with its neighbors to include members of small establishments, where 90 percent of the labor force works?

This occupational health maintenance know-how would be a wonderful fringe benefit, not only for all of us who work for a living, but for everyone we support.

I can visualize regional health protection centers being operated by either private enterprise or government or conjointly, but why cannot group contracts be worked out at very reasonable per-person cost to business, industry, occupational or professional groups, as a fringe benefit to be paid for out of earned income?

It seems to me it is better for the recipients to pay directly at the source, rather than indirectly and more expensively out of taxes. We would find a substantial profit from this investment to be increased production, increased productive capacity, for all of us.

A government can team up with free enterprise, and vice versa. The Public Health Service and the Kaiser Foundation Research Institute have opened a gate. I plead that any new health protection center do as they have done, learn the techniques by servicing their own.

They who cast out first mistakes they learn on themselves can see more clearly to prevent more costly mistakes in their services to others.

Then I recommend for consideration an initial screening schedule, which it is no use in my reporting here, because it is in the paper. And I will leave you with this comment: that perhaps, just perhaps, if this Nation learns how to provide health maintenance for its labor force, paid for out of earned income, perhaps it then can see more clearly how to make it available for the rest of the population.

Senator Neuberger, I have seen sick call for the few crowd out health service for the many. At any one time in these United States, about 3 percent of our population are under medical care or other professional care for sickness or injury.

That leaves 97 percent of our population as of today that are not under any kind of professional care for sickness or injury, as of today, right now.

And I have seen so often this sick call for the relatively few, the 3 percent, crowd out health service for the many.

Almost everyone gives lipservice to prevention, but unfortunately, most shift the responsibility to anyone other than themselves.

The matters we are considering here today have the potential for overcoming some of the apathy-that is, both professional apathy and public apathy-but only if the essential, cardinal principles such as I outlined in my paper are adhered to.

Now, since I submitted my original paper, the following additional pertinent information has become available, and I have appended it to an amended copy of the paper. I think perhaps it is in the one you have. I don't know.

One; a letter from the President of the Fulton County Medical Society-that is in Atlanta, Ga.

And two; certain estimations of indirect costs in Georgia, which we adapted from the national estimates that you heard about yesterday from Dorothy Rice. Startling figures in Georgia calculated for diseases of the circulatory system, arthritis, and rheumatism, diseases of the respiratory system, cancer, and tuberculosis, total indirect costs for only these five groups, in just one State, of $206,480,000.

The computation of these costs rests on two assumptions, (1), that chronic illness is distributed in Georgia as it is in the coterminous United States, and (2), that the cost of illness is the same in Georgia as it is in the coterminous United States. So these costs should be regarded as a thesis subject to test, rather than as a fact.

I want to thank you again for the privilege of presenting these thoughts. I take full responsibility for them. They do not necessarily reflect in their entirety established policies of the Georgia Department of Public Health.

However, they have been reviewed by professional members of my own department. They have also been reviewed by the chairman of the Georgia Commission on Aging, and by the president and presidentelect of the Medical Association of Georgia, without dissent.

Thank you.

(Dr. Petrie's prepared statement follows:)

PREPARED STATEMENT BY LESTER M. PETRIE, M.D., M.P.H., F.A.C.P.

Senator Neuberger, Members of the Subcommittee, and Guests:

My discussion today will be devoted largely to costs and consequences of chronic disease in Georgia and the effect of a modern health screening program on its consequences and upon the workload of the medical profession.

We have had some success and some disillusionment with multi-test health screening in Georgia. From 1945 to 1953 1.4 million citizens of our State voluntarily submitted to the prick of the needle and the radiation of X-ray so that they could "know for sure" about their health. I now think our propaganda "know for sure" was some of the worst we ever put out. It sure did bring the people to the examining stations-but on a false premise-for neither we nor they could "know for sure" just by a laboratory test. There is no easy short cut to correct medical diagnosis of disease.

However, an ancillary benefit of the survey technique proved to be its effectiveness as a health education tool if correctly used. It motivated nearly 70% of our population age 15 and over (eighty to ninety percent of them not otherwise under medical supervision) to voluntarily do something to protect their own health. And, it did find and bring to treatment 130,000 cases of syphilis ; and many cases of other diseases, previously hidden and unknown, were referred to private physicians for diagnosis and treatment.

The most important factor which assured success in spite of mistakes was the priceless inheritance of close harmony between the Health Department on the one hand and the Medical Societies and private practitioners on the other. They worked together guiding our affairs. They fixed the pattern of cooperation without which real success in such a venture would be impossible.

May I first discuss certain costs and consequences of chronic disease. Thirty years ago, public health in Georgia was not too concerned about diabetes, glaucoma, hypertension, or arthritis because we were too overwhelmed with malaria and typhoid fever and pellagra, etc. Six hundred and six (606) deaths from malaria were reported in 1936. It is estimated that there were over 120,000 cases. In that same year there were 195 reported deaths and 926 reported cases of typhoid fever, and probably hundreds of unreported cases. There were 391 deaths from pellagra and unnumbered cases. Sickness was one of the basic reasons that President Roosevelt could categorize the South as "the economic problem number one". Sickness transmitted by a malaria infected mosquito, or

a human typhoid carrier, or an inadequate diet or otherwise, was a major reason why industry in Georgia could not prosper in those days.

Many millions of public health dollars were spent in malaria control work. Epidemiological investigations to identify and control the factors and their interrelationships which affected the occurrence and course of disease in our population did not come cheap. Laboratories identified malaria parasites in human blood and in anopheles mosquitos. Breeding places of mosquito larvae were found and treated or eradicated. Swamps were drained. Houses were screened. Public education was fostered. With the advent of D.D.T. houses and outbuildings were sprayed. By 1950 the job was done except for relatively inexpensive surveillance which still continues. No confirmed malaria transmission has occurred in Georgia since 1950 except for one case acquired at Fort Benning in 1964 and one more in 1965. Similar epidemiological investigations provided the framework for the control of typhoid and pellagra and other diseases. As a result industry was and is able to prosper in Georgia. Our multibillion-dollar economy today justifies the public health investment which helped make it possible. Elsewhere the 2 billion people living in less fortunate countries where disease rates are high, life expectancy is low, and production of wealth is insufficient, should be a constant reminder to us that to have either health or wealth a nation must have both.

The above dramatizes benefits from the control of certain diseases within our lifetime. Other examples could be cited such as smallpox. There are still other diseases which are partially controlled, including:

1. Syphilis.-A serologic test for syphilis was included in our community-wide multiphasic screening surveys in Georgia. There were 130,000 cases of syphilis brought or returned to treatment, of which 33,033 were previously unknown and untreated; 1,017 of the previously unknown and untreated cases were primary or secondary syphilis. The majority of the primary and secondary cases were found by epidemiological investigation of contacts of infectious cases rather than directly by the screening. Contact investigation of all infectious cases of syphilis is a continuing program. Prior to this program, 20 percent of the inmates in our State mental hospital were there because of central nervous system syphilis. Today, new admissions for psychoses attributable to syphilis are negligible. Secondary prevention of chronic tertiary syphilis has been accomplished. Last year, 2,516 cases of syphilis, of which 1,004 were primary or secondary, were found and brought to treatment. (See Table I appended.)

2. Tuberculosis.-Primary prevention, and even eradication of tuberculosis is possible, yet there were 117 deaths in Georgia in 1964 (2.8 per 100,000). A more realistic measure of the persons now directly affected by tuberculosis in Georgia is the sum of the 2,531 active cases on our register, the 6,000 cases where disease was active less than five years ago, and the 10,000 to 11,000 contacts to newly reported cases; a total of approximately 20,000 persons. The annual cost is well over 5.5 million dollars. The average annual cost for maintaining a citizen in the State Tuberculosis Hospital is $6,333. On the other hand, the average annual buying power of a citizen of metropolitan Atlanta today is $2,520 after taxes. How much beter it is for a citizen to annually contribute $2,520 to our economy over and above his taxes rather than to contribute nothing but extract 21⁄2 times that amount from the taxpayers.

During multiphasic screening years 7,000 cases of tuberculosis were found (6.4 cases per 1,000) and an additional 6,000 suspects (5.8 cases per 1,000). Unfortunately, we did not do intensive epidemiologically oriented follow up. In later years we resurveyed some of the same communities and found the same old cases over again less the ones who had died and plus a few new ones. In far too many instances we found very little evidence of adequate curative treatment for the cases, or of adequate contact investigations to find the source cases or to prevent spread to new cases. This experience convinced us that screening is not an objective in itself. Multiphasic screening is useless unless provision has been made for the necessary epidemiological follow up and control of all the key factors which interrelate to affect the occurrence and course of the diseases, and to assure availability of adequate medical diagnosis and care to the patients. Multiphasic screening is capable of swamping the medical and health facilities of any community which has not been prepared to diagnose the suspects and care for the cases found.

Many more chronic diseases remain partially or completely uncontrolled. Their prevalence has always been very difficult to determine since deaths only are reportable. Estimates of prevalence of some of them based on published findings of the National Health Survey have been calculated by our Epidemiologic